Is Canada’s COVID-19 problem much bigger than we think?

"Accurately counting COVID-19 deaths is important for reasons beyond the numbers themselves. Having the right data is essential if we’re deciding to relax social distancing measures based on supposed success in flattening the curve."

A view of the main entrance to the Pinecrest Nursing Home is seen on Wednesday March 25, 2020 in Bobcaygeon, Ont. Torstar File photo

It’s become increasingly clear that Canada’s COVID-19 problem lies mainly in the nation’s nursing homes. Yet as bad as the situation is, there are worrying signs that it may actually be even worse and that authorities in Ontario and Quebec are significantly understating the true number of deaths from COVID-19.

At homes in both Ontario and Quebec, discrepancies have emerged between the number of deaths attributed to COVID-19, and much larger increases in deaths in those facilities since the start of the pandemic.

According to a detailed analysis by the Toronto Star, Ontario’s public health authorities have widely under-reported deaths in long-term care homes. While the province’s death count is at 144, the Star has found that regional health authorities and local media have reported 50 per cent more deaths, or 219. The problem is based in part on bureaucratic delays.

Radio-Canada reports that in Quebec, those who die outside of hospitals — in care facilities or at home — are seldom tested for the virus and doctors are hesitant to identify COVID-19 as the cause of death, even when they believe it’s likely. If those reports are correct, there is good reason to believe that COVID-19 deaths are being undercounted.

“There’s been a significant under-reporting of deaths in Ontario,” Laura Tamblyn Watts, chief executive of CanAge, a seniors’ advocacy group told us. Until recently, when more than three COVID-19 cases were identified in an Ontario care home, an outbreak was declared and, usually, no further testing was done, she explained. If one of the residents who tested positive died, it would be counted as a COVID-19 death. Not so for any subsequent deaths in untested patients, and post-mortem testing is not systematically performed.

“It appears obvious that in the acute phase, in March and April, deaths are being missed,” said Prabhat Jha, an epidemiologist and director of the Centre for Global Health Research at St. Michael’s Hospital in Toronto.

Under-reporting is a global problem, but some authorities are attempting to correct the situation. In New York City, the COVID-19 death toll increased dramatically this week by about 3,700 cases, as authorities reviewed mortality data. In the United Kingdom, the Office of National Statistics estimated that COVID-19 deaths were at least 10 percent higher than previously thought, due again to unreported deaths from nursing homes.

Reporting and measuring deaths amid the chaos of a pandemic is challenging. Attributing a cause of death is not always straightforward, and with COVID-19 severely ill patients tend to have other underlying medical conditions, further muddying the waters. Tests are in limited supply, particularly in Ontario, where testing has been sub-par from the start.

A few extra deaths here and there might seem like mere statistical error, but small numbers quickly add up to significant discrepancies. Even 50 missed deaths in two nursing homes, as recent reports from Quebec point to, represents more than 10 per cent of the current COVID-19 death toll for the province. With thousands of nursing and retirement homes in Canada, it’s easy to understand how our accounting could be seriously off the mark.

In an evolving pandemic, timing matters as well. Even though testing has been scaled up in many Canadian jurisdictions, it’s unlikely that someone who fell ill early in the outbreak would have been tested unless they had traveled abroad or had been hospitalized. It’s clear that many deaths over the past month may actually have been caused by undiagnosed coronavirus infections contracted before more widespread testing was in place.

As our efforts to stop the spread of coronavirus have monopolized our hospitals and limited access to healthcare for non-coronavirus patients, there have certainly been indirect deaths from COVID-19, as patients delay seeking or cannot access care for other serious conditions. Properly accounting for those deaths is another challenge, and one that will likely take time, but certain basic measures of mortality could help.

Accurately counting COVID-19 deaths is important for reasons beyond the numbers themselves. Having the right data is essential if we’re deciding to relax social distancing measures based on supposed success in flattening the curve. Since we lack widespread testing, deaths are our best proxy of outbreak severity. The mortality curve can flatten because deaths are truly stabilizing, or simply because we’re not counting them properly. The problem right now is that we simply don’t know, and it’s unclear if those in charge do either.

We need more transparency from government, which could make extra efforts to bypass the existing cumbersome systems in order to collect and disseminate critical data in real time. The UK and France publish weekly overall mortality data, so it’s possible to determine the number of excess deaths since the outbreak began. Not so in Canada, where the provinces are slow at reporting and national numbers must be compiled by Statistics Canada.

Counting deaths is crucial to our pandemic response and to government accountability. Our politicians should be on notice, since at least one recent death-counting scandal has brought down a government. Governor Ricardo Rosselló of Puerto Rico was forced out of office by mass protests in 2019, after significantly understating the huge death toll from Hurricane Maria.

The views, opinions and positions expressed by all iPolitics columnists and contributors are the author’s alone. They do not inherently or expressly reflect the views, opinions and/or positions of iPolitics.

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Samuel Freeman is a pediatrician and writer in Montreal. Alan Freeman is an iPolitics columnist and Honorary Senior Fellow at the University of Ottawa’s Graduate School of International and Public Affairs.